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February 05, 2013; 80 (6) Article

Neighborhood socioeconomic disadvantage and mortality after stroke

Arleen F. Brown, Li-Jung Liang, Stefanie D. Vassar, Sharon Stein Merkin, W.T. Longstreth, Bruce Ovbiagele, Tingjian Yan, José J. Escarce
First published January 2, 2013, DOI: https://doi.org/10.1212/WNL.0b013e31828154ae
Arleen F. Brown
From the Division of General Internal Medicine and Health Services Research (A.F.B., L.-J.L., J.J.E.), Department of Neurology (S.D.V., B.O., T.Y.), and Division of Geriatrics (S.S.M.), University of California, Los Angeles; Departments of Neurology and Epidemiology (W.T.L.), University of Washington, Seattle; Department of Neurosciences (B.O.), University of California, San Diego; SCAN Healthplan (T.Y.), Long Beach, CA; and RAND (J.J.E.), Santa Monica, CA.
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Li-Jung Liang
From the Division of General Internal Medicine and Health Services Research (A.F.B., L.-J.L., J.J.E.), Department of Neurology (S.D.V., B.O., T.Y.), and Division of Geriatrics (S.S.M.), University of California, Los Angeles; Departments of Neurology and Epidemiology (W.T.L.), University of Washington, Seattle; Department of Neurosciences (B.O.), University of California, San Diego; SCAN Healthplan (T.Y.), Long Beach, CA; and RAND (J.J.E.), Santa Monica, CA.
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Stefanie D. Vassar
From the Division of General Internal Medicine and Health Services Research (A.F.B., L.-J.L., J.J.E.), Department of Neurology (S.D.V., B.O., T.Y.), and Division of Geriatrics (S.S.M.), University of California, Los Angeles; Departments of Neurology and Epidemiology (W.T.L.), University of Washington, Seattle; Department of Neurosciences (B.O.), University of California, San Diego; SCAN Healthplan (T.Y.), Long Beach, CA; and RAND (J.J.E.), Santa Monica, CA.
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Sharon Stein Merkin
From the Division of General Internal Medicine and Health Services Research (A.F.B., L.-J.L., J.J.E.), Department of Neurology (S.D.V., B.O., T.Y.), and Division of Geriatrics (S.S.M.), University of California, Los Angeles; Departments of Neurology and Epidemiology (W.T.L.), University of Washington, Seattle; Department of Neurosciences (B.O.), University of California, San Diego; SCAN Healthplan (T.Y.), Long Beach, CA; and RAND (J.J.E.), Santa Monica, CA.
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W.T. Longstreth Jr
From the Division of General Internal Medicine and Health Services Research (A.F.B., L.-J.L., J.J.E.), Department of Neurology (S.D.V., B.O., T.Y.), and Division of Geriatrics (S.S.M.), University of California, Los Angeles; Departments of Neurology and Epidemiology (W.T.L.), University of Washington, Seattle; Department of Neurosciences (B.O.), University of California, San Diego; SCAN Healthplan (T.Y.), Long Beach, CA; and RAND (J.J.E.), Santa Monica, CA.
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Bruce Ovbiagele
From the Division of General Internal Medicine and Health Services Research (A.F.B., L.-J.L., J.J.E.), Department of Neurology (S.D.V., B.O., T.Y.), and Division of Geriatrics (S.S.M.), University of California, Los Angeles; Departments of Neurology and Epidemiology (W.T.L.), University of Washington, Seattle; Department of Neurosciences (B.O.), University of California, San Diego; SCAN Healthplan (T.Y.), Long Beach, CA; and RAND (J.J.E.), Santa Monica, CA.
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Tingjian Yan
From the Division of General Internal Medicine and Health Services Research (A.F.B., L.-J.L., J.J.E.), Department of Neurology (S.D.V., B.O., T.Y.), and Division of Geriatrics (S.S.M.), University of California, Los Angeles; Departments of Neurology and Epidemiology (W.T.L.), University of Washington, Seattle; Department of Neurosciences (B.O.), University of California, San Diego; SCAN Healthplan (T.Y.), Long Beach, CA; and RAND (J.J.E.), Santa Monica, CA.
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José J. Escarce
From the Division of General Internal Medicine and Health Services Research (A.F.B., L.-J.L., J.J.E.), Department of Neurology (S.D.V., B.O., T.Y.), and Division of Geriatrics (S.S.M.), University of California, Los Angeles; Departments of Neurology and Epidemiology (W.T.L.), University of Washington, Seattle; Department of Neurosciences (B.O.), University of California, San Diego; SCAN Healthplan (T.Y.), Long Beach, CA; and RAND (J.J.E.), Santa Monica, CA.
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Citation
Neighborhood socioeconomic disadvantage and mortality after stroke
Arleen F. Brown, Li-Jung Liang, Stefanie D. Vassar, Sharon Stein Merkin, W.T. Longstreth, Bruce Ovbiagele, Tingjian Yan, José J. Escarce
Neurology Feb 2013, 80 (6) 520-527; DOI: 10.1212/WNL.0b013e31828154ae

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Abstract

Objective: Residence in a socioeconomically disadvantaged community is associated with mortality, but the mechanisms are not well understood. We examined whether socioeconomic features of the residential neighborhood contribute to poststroke mortality and whether neighborhood influences are mediated by traditional behavioral and biologic risk factors.

Methods: We used data from the Cardiovascular Health Study, a multicenter, population-based, longitudinal study of adults ≥65 years. Residential neighborhood disadvantage was measured using neighborhood socioeconomic status (NSES), a composite of 6 census tract variables representing income, education, employment, and wealth. Multilevel Cox proportional hazard models were constructed to determine the association of NSES to mortality after an incident stroke, adjusted for sociodemographic characteristics, stroke type, and behavioral and biologic risk factors.

Results: Among the 3,834 participants with no prior stroke at baseline, 806 had a stroke over a mean 11.5 years of follow-up, with 168 (20%) deaths 30 days after stroke and 276 (34%) deaths at 1 year. In models adjusted for demographic characteristics, stroke type, and behavioral and biologic risk factors, mortality hazard 1 year after stroke was significantly higher among residents of neighborhoods with the lowest NSES than those in the highest NSES neighborhoods (hazard ratio 1.77, 95% confidence interval 1.17–2.68).

Conclusion: Living in a socioeconomically disadvantaged neighborhood is associated with higher mortality hazard at 1 year following an incident stroke. Further work is needed to understand the structural and social characteristics of neighborhoods that may contribute to mortality in the year after a stroke and the pathways through which these characteristics operate.

Glossary

CHS=
Cardiovascular Health Study;
CI=
confidence interval;
CVD=
cardiovascular disease;
DBP=
diastolic blood pressure;
HDL=
high-density lipoprotein;
HR=
hazard ratio;
IRB=
institutional review board;
NSES=
neighborhood socioeconomic status;
SBP=
systolic blood pressure;
SES=
socioeconomic status;
TC=
total cholesterol

Footnotes

  • Go to Neurology.org for full disclosures. Funding information and disclosures deemed relevant by the authors, if any, are provided at the end of the article.

  • Supplemental data at www.neurology.org

  • Editorial, page 516

  • Received June 14, 2012.
  • Accepted October 2, 2012.
  • © 2013 American Academy of Neurology
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Disputes & Debates: Rapid online correspondence

  • Neighborhood socioeconomic disadvantage and mortality after stroke
    • Manoj K. Mittal, Neurocritical Care Fellow, Mayo Clinic, Rochester, MNmittal.manoj@mayo.edu
    • Jennifer B. McCormick, Rochester, MN
    Submitted July 01, 2013
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